The Relationship of School Participation with Motor Proficiency and Executive Function in Children with Autism Spectrum Disorder

Objectives: Participation in meaningful activities is an important aspect of development in children with developmental disorders such as autism spectrum disorder (ASD). The purpose of this study was to assess the correlation of school participation with motor proficiency and executive function in children with ASD. Materials & Methods In this cross-sectional (descriptive-analytic) study, 52 students aged 6 to 12 years old with ASD were selected through the convenience sampling method. The GARS-2 scale was used to confirm ASD diagnosis. Other psychiatric comorbidities such as ADHA were studied by the CSI-4 tool, and students with comorbidities were excluded. Data were collected using SFA, BOTMP-2, and BRIEF questionnaires. It should be noted that in the BRIEF questionnaire, a higher score indicates a more severe disability. Results Our findings showed that motor proficiency and its components had a significant direct correlation with school participation in children with ASD (P ≤0.001). On the other hand, school participation was inversely and significantly correlated with the behavioral regulation and metacognition monitoring indices of the executive function dimension (P <0.05). Conclusion Based on the findings of this research, the development of motor proficiency and improvements in the behavioral regulation and metacognition monitoring of students with ASD will boost their participation in school activities. Motor proficiency was significantly correlated with school participation in children with ASD. More attention should be paid to perceptual motor interventions and cognitive rehabilitation programs (with a focus on monitoring metacognition and shifting behavioral regulation) to increase the participation of children with ASD in school activities.


Introduction
Participation is a frequently-used concept in occupational therapy and other health sciences. School participation refers to the student's ability to grasp opportunities and actively participate in the roles corresponding to his/her age and culture (4). Participation in school activities has been noted to enhance ASD children's well-being and quality of lives (2). The unique characteristics of children with ASD influence their experiences at school (5).
Although numerous studies have been conducted on the participation of children with disabilities in school activities, such studies on children with ASD have been neglected despite the increasing number of these children (6). In their research on children with ASD, Vatrayan et al. (2015) reported that visual perception and the imitation of movements were associated with the children's levels of participation in school activities (7). Hsiao concluded that there was a significant correlation between daily motor functions and academic performance in these children (18). Given the participation problems faced by children with ASD at school and the role of occupational therapists in school-based interventions, identifying the factors associated with school participation in these children seems to be beneficial for implementing effective interventions. Therefore, considering the points raised, the present study was conducted to determine the relationship between school participation and motor proficiency and executive function in children with ASD.

Procedure
This was a correlational and cross-sectional given to them. The parents were asked to complete the questionnaires and return them to the school principal within three days. Sixty-seven parents filled out the questionnaires; however, due to the diagnosis of comorbidities, the forms of children with ADHD (n=15) were excluded from the study, and the questionnaires received from the rest of the parents (n=52) were analyzed. Afterward, the School Function Assessment (SFA) questionnaire was administered to the children's teachers to fill it out. Teachers also responded to a series of questions, for some of which they asked assistance from the school principal, the sports teacher, and caregivers.
The BOTMP-2 motor proficiency Test was run in a room at the school. The test's subcomponents were administered in such an order that was consistent with each student's condition. In this regard, for the evaluation of the students who had less sustained attention and couldn't tolerate sitting in their places, the tests started with the subcomponents of gross motor skills and coordination. If the child could tolerate the test on the same day, he/she was asked to keep on performing fine motor skills; otherwise, the rest of the assessment would be postponed to another day. Some students did not cooperate well in performing the tests of gross motor skills and coordination and were more willing to do paper and pencil tasks; so, their assessment began by testing their subtle fine motor skills. Likewise, based on students' conditions, the tests were either administered on the same day or postponed to the next days.

Statistical Analysis
The data were analyzed by SPSS 21 software using the Pearson correlation coefficient.

Results
The average age of the children participating in the present study was 117 months. All of the subjects were 6-to 12-year-old boys. Five of them were in pre-elementary, and 25, 8, 5, and 9 were in the first, second, third, and fourth grades, respectively (Table   1) Table 3). It should be noted that in the BRIEF scale, the higher the score is, the weaker the performance will be. So, the observed negative correlation coefficients do not mean that participation has an inverse relationship with the shift and monitoring subcomponents.   Tasks such as participating in classroom activities, eating, and toileting involve the activities requiring working with paper, pencil, and manipulative tools (32)(33)(34). Therefore, school participation is the most relevant factor to fine motor skills. On the whole, it can be concluded that the motor proficiency of students with ASD is positively correlated with participation in school activities. Limitations One of the limitations of the present study was the lack of access to the same number of students in each grade.

Suggestions
Considering the importance of participating in school activities, which is a great concern of the parents of children with ASD, it is suggested that and cognitive rehabilitation be assessed on these children's school participation rates.

In Conclusion
The

Author's Contribution
Mehdi Alizadeh Zarei developed the idea and methodology and was the supervisor of the project and the author of the article. Mahsa Kheirollahzadeh conducted the research and wrote the article.
Malek Amini and Faezeh Dehghan were research collaborators and consultants.